Use of SGLT‐2 inhibitor in COVID‐19: A cautionary tale

Abstract

Dear Editor, SGLT-2 inhibitors are oral antidiabetic agents with a low risk of hypoglycemia. They block glucose reabsorption at the proximal tubule, leading to glucosuria and thus lowering plasma glucose levels. SGLT-2 inhibitors have an added benefit of weight loss and a reduction of blood pressure. Diabetic ketoacidosis (DKA) is a serious condition resulting from a relative insulin deficiency in the body and is characterized by marked hyperglycemia and ketoacidosis. Patients on sodium-glucose co-transporter-2 (SGLT-2) inhibitors have a two-fold higher risk of developing DKA shortly after initiation, compared to dipeptidyl peptidase4 (DPP4) inhibitors.1 Furthermore, they may suffer from ketoacidosis in the absence of profoundhyperglycemia due to urinary glucose loss.2 We stress this point by describing a case of euglycemic DKA in a COVID-19 patient, where Kussmaul breathing mimicked respiratory distress. This project has been approved by the medical research council of HamadMedical Corporation under the project IDMRC04-20-636. A 49-year-old male, known case of type 2 diabetes mellitus diagnosed 5 months back, presented with fever, fatigue, mild dry cough, and flu-like symptoms. He had exposure to a coworker with COVID-19. He was a nonsmoker and did not use alcohol or any illicit drugs. He had normal vital signs and an unremarkable clinical examination. A SARS-CoV-2 reverse transcriptase-polymerase chain reaction employing the GeneXpert technique from a combined nasopharyngeal and throat swab was sent and turned out to be positive. His complete blood count, electrolytes, inflammatory markers, liver, and renal function were within normal limits. A random blood sugar of 14.8 mmol/L was noted, and HbA1C was 8.9%. The patient’s home medications consisted only of metformin 1 g twice daily. Dapagliflozin 10 mg daily was added to his oral antidiabetic regimen. He was discharged after 24 hours of observation on as needed cough suppressant and acetaminophen. Five days after his discharge, the patient presented to the hospital again complaining of worsening fatigue, nausea,